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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> AUTHORIZATION TO RELEASE <br /> ' ANALYTICAL RESULTS <br /> ' GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT ILUS BOur6N C.+s e-ef �I�KCOn <br /> (Street Address)' 11 <br /> HEREBY AUTHORIZE ATEL �1 SSOCts+l(� �n V�RP� <br /> (laboratory or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. r I <br /> BUSINESS NAME: 1'QC�( f 1 t I1 <br /> (If Applicable) I r I f r <br /> OWNER/OPERATOR: &eya <br /> (Please Print) (Title) <br /> (Owwnef Operator Signature) Q <br /> ADDRESS: 6MI X t rINCI� POJ <br /> (Mailing Address) !l <br /> �fAr. )`,)S r N- �El x <br /> (City) p (state) (Zip Code) <br /> PHONE: ( /� 1 O 2K9—w <br /> DA 106 <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />